Welcome to In-unit Seminar on Nutritional Management of Diabetes Mellitus Meera kaur, Ph.D., R.D. May 13, 2009.

Welcome to In-unit SeminarWelcome to In-unit Seminaron on

Nutritional Management of Nutritional Management of Diabetes MellitusDiabetes Mellitus

Meera kaur, Ph.D., R.D.Meera kaur, Ph.D., R.D.

May 13, 2009May 13, 2009

Nutritional Management of DM..Nutritional Management of DM..

Goals are to Goals are to – achieve target blood sugar levelachieve target blood sugar level– achieve and maintain desirable body weightachieve and maintain desirable body weight– prevent the complicationsprevent the complications– manage the complications if already developedmanage the complications if already developed– improve the overall quality of lifeimprove the overall quality of life

Nutritional Management of DM..Nutritional Management of DM..At the bottom line:At the bottom line:– To follow Canada’s Food Guide for Healthy EatingTo follow Canada’s Food Guide for Healthy Eating– Carbohydrates: 45-60% of energy (choose Carbohydrates: 45-60% of energy (choose

complex CHO with low glycemic index)complex CHO with low glycemic index)– Protein: 15-20% of energy (encourage more fish Protein: 15-20% of energy (encourage more fish

than meat, specially fatty fish)than meat, specially fatty fish)

– Fat: Fat: <<35% of energy (SFA:35% of energy (SFA: <<%7, PUFA: %7, PUFA: <<%10; %10; include PUFA-especially n-3 PUFA)include PUFA-especially n-3 PUFA)

– Vitamins+Minerals: Routine supplementation is Vitamins+Minerals: Routine supplementation is not necessarynot necessary

– Alcohol: Alcohol: <14 and <9 std. drinks for men and women/week respectively

Nutritional Management of DMNutritional Management of DMAt the bottom line:At the bottom line:– Referral to RDReferral to RD– Education to those patients on intensive insulin Education to those patients on intensive insulin

therapy about matching insulin to CHO content of therapy about matching insulin to CHO content of meals (CHO counting)meals (CHO counting)

– Weight managementWeight management– Regular physical activitiesRegular physical activities– Team approachTeam approach

Glycemic Control in Canada

Uncontrolled AIC49%

Controlled AIC51%

One in two type-2 diabetes patients in Canada are not at target (<7%).

Glycemic Control in CanadaGlycemic Control in Canada

Even though only ½ have glycemic Even though only ½ have glycemic control, only 12% of patients are control, only 12% of patients are currently on insulin.currently on insulin.

Harris, E. et al, Diabetes Res Clin Pract 2005;70:90.Harris, E. et al, Diabetes Res Clin Pract 2005;70:90.

Risk Reduction for Diabetes By Achieving a Specific Risk Reduction for Diabetes By Achieving a Specific Lifestyle Target – Diabetes Prevention StudyLifestyle Target – Diabetes Prevention Study

GoalGoal RRR(%)RRR(%)

Weight Loss >5%Weight Loss >5% 6666

Total Fat <30% EnergyTotal Fat <30% Energy 5353

Saturated Fat <10% Saturated Fat <10% EnergyEnergy

5454

Fiber >15 gram/100kcalFiber >15 gram/100kcal 7171

Exercise >4 hours/weekExercise >4 hours/week 6262

N Eng J Medicine 2001: 344: 1343-50.

Glycemic IndexGlycemic Index– Has been around for over 20 years.Has been around for over 20 years.– May help to:May help to:

Control blood glucose levels Control blood glucose levels

Control cholesterol levels Control cholesterol levels

Control appetite Control appetite

Lower risk of getting heart disease Lower risk of getting heart disease

Lower risk of getting type 2 diabetes Lower risk of getting type 2 diabetes – Ranks foods by how much they raise blood glucose Ranks foods by how much they raise blood glucose

levels compared to glucose or white bread.levels compared to glucose or white bread.– In general, the lower the rating, the better the quality of In general, the lower the rating, the better the quality of

carbohydrate. carbohydrate.

Usually low in calories and fat, while also being high Usually low in calories and fat, while also being high in fiber, nutrients and antioxidants. in fiber, nutrients and antioxidants.

– Size of particleSize of particle– CookingCooking

Spaghetti boiled 5 min Spaghetti boiled 5 min GI = 34GI = 34Spaghetti boiled 10-15 minSpaghetti boiled 10-15 min GI = 40GI = 40

– ProcessingProcessingCornflakesCornflakes GI = 86GI = 86PorridgePorridge GI = 49GI = 49

– Fat (Lowers GI)Fat (Lowers GI)Potato ChipsPotato Chips GI = 75GI = 75Baked PotatoBaked Potato GI = 93GI = 93

– Acidity – lower pH slows gastric emptying= lowers GIAcidity – lower pH slows gastric emptying= lowers GI– Mixture of meals (Protein, Fat, CHO)Mixture of meals (Protein, Fat, CHO)

What Affects GI?What Affects GI?

Blood Glucose LevelsBlood Glucose Levels

Time (2 hours)

Blo

od G

luco

se

GlucoseLentils

Glycemic Load vs. Glycemic Glycemic Load vs. Glycemic IndexIndex

The glycemic load is calculated by multiplying The glycemic load is calculated by multiplying the glycemic index by the amount of CHO in the glycemic index by the amount of CHO in grams provided by a food and dividing the total grams provided by a food and dividing the total by 100.by 100.– Takes into account quality (glycemic index) and Takes into account quality (glycemic index) and

quantity of CHO in a meal.quantity of CHO in a meal.

Glycemic Load may be a better indicator.Glycemic Load may be a better indicator.– Confuses the issue even more.Confuses the issue even more.

Better Yet…Better Yet…

Better to give direct Better to give direct recommendations. recommendations. – Increase whole grains, nuts, legumes, Increase whole grains, nuts, legumes,

fruits, and non-starchy vegetables.fruits, and non-starchy vegetables.

– Decrease white stuff, desserts, and pop.Decrease white stuff, desserts, and pop.

FiberFiber

InsolubleInsoluble

SolubleSoluble– Improves glucose controlImproves glucose control

All about MealsAll about Meals

Quantity is important.Quantity is important.– What foods have CHO in them?What foods have CHO in them?

Quality is importantQuality is important– Foods that slow digestion (protein, fibre) vs. foods that Foods that slow digestion (protein, fibre) vs. foods that

speed through (soft drinks, candy).speed through (soft drinks, candy).Protein at each meal.Protein at each meal.

20-30 g fiber each day.20-30 g fiber each day.

Spacing of meals.Spacing of meals.– Wave Effect. Want consistency.Wave Effect. Want consistency.– Meals should be 3-4 hours apart.Meals should be 3-4 hours apart.– Do not skip meals.Do not skip meals.

What your plate should look What your plate should look like…like…

Other Important Lifestyle Other Important Lifestyle changes…changes…

ExerciseExercise– 150 minutes per week of moderate-intensity aerobic 150 minutes per week of moderate-intensity aerobic

physical activity.physical activity.Should be at least 3 days/week, no more than 2 consecutive days Should be at least 3 days/week, no more than 2 consecutive days without physical activity.without physical activity.Same recommendation for those with impaired fasting blood Same recommendation for those with impaired fasting blood glucose or diabetes.glucose or diabetes.

– Stress test may be needed.Stress test may be needed.– Consistent exercise for 8 weeks can lower HgA1C by 1% Consistent exercise for 8 weeks can lower HgA1C by 1%

(New Recommendations Regarding Exercise and type 2 Diabetes )(New Recommendations Regarding Exercise and type 2 Diabetes )

Weight lossWeight loss– Even 5-10% of BW makes a difference.Even 5-10% of BW makes a difference.

Shows improvement in glycemic control, lipid profiles, insulin Shows improvement in glycemic control, lipid profiles, insulin sensitivity and BP.sensitivity and BP.

Inadequate More than 14 Action Required

Suboptimal 11-14 Action May be Required

Ideal 5-10 Target Goal

Inadequate More than 10 Action Required

Suboptimal 7-10 Action may be Required

Ideal 4-7 Target Goal

Too Low Less than 4 Risk of Reaction High

Fasting or Before Meals

One or Two Hours after a Meal

UKPDS: Decreased Risk of Diabetes Related UKPDS: Decreased Risk of Diabetes Related Complications Associated with a 1% Decrease in A1CComplications Associated with a 1% Decrease in A1C

C ataract

e xtractio n

-1 9 %

P e r ip h e ra l

v ascu lar d ise ase

-4 3 %

S tro ke

-1 2 %myo card ia l

in farc tio n

All-cau se

mo rta lity

-1 4 %D iab e te s-re la te d

d e ath ,

-2 1 %

M acro v ascu lar

d ise ase

-3 7 %

An y d iab e te s-re la te d

e n d p o in t,

-2 1 %

-5 0

-4 0

-3 0

-2 0

-1 0

0

P e rc e nta g e inc re a s e in re la t iv e r is k c o rre s p o nd ing to a 1 % r is k in H b A1 C

Adapted from Stratton, IM, et al. UKPDS 35. BMJ 2000; 321:405.

BOTTOM LINE: We need to be BOTTOM LINE: We need to be controlling blood sugars better!controlling blood sugars better!

Require:Require:– Appropriate glucose monitoringAppropriate glucose monitoring

Learning meaning behind test resultsLearning meaning behind test results

Using test results to understand the link between Using test results to understand the link between food and blood glucose.food and blood glucose.

– Important for all people with diabetes.Important for all people with diabetes.

Modern insulin thinkingModern insulin thinking– If their sugars are not in control, use all that is in your If their sugars are not in control, use all that is in your

toolbox.toolbox.

Adaptive thinking.Adaptive thinking.

When starting insulin…When starting insulin…

Rapid actingRapid acting– Humalog/NovoRapidHumalog/NovoRapid

Target PPG = 7-8 mmol/LTarget PPG = 7-8 mmol/L

Select largest meal firstSelect largest meal first

Start with low dose : 4-6 u and titrateStart with low dose : 4-6 u and titrate

Adjust for the meal contentAdjust for the meal content

Less hypoglycemiaLess hypoglycemia

Carbohydrate CountingCarbohydrate Counting

1 CHO Choice = 15 gram CHO1 CHO Choice = 15 gram CHO

MalesMales– 3-5 CHO choices, 1 protein choice per meal3-5 CHO choices, 1 protein choice per meal– 1-3 CHO choice, ½ protein choice per snack1-3 CHO choice, ½ protein choice per snack

FemalesFemales– 2-4 CHO choices, 1 protein choice per meal2-4 CHO choices, 1 protein choice per meal– 1-2 CHO choice, ½ protein choice per snack1-2 CHO choice, ½ protein choice per snack

Hypoglycemia GuidelinesHypoglycemia Guidelines

Rule of 15Rule of 15

If <4 mmol/LIf <4 mmol/L– Treat with 15 grams CHO (glucose or Treat with 15 grams CHO (glucose or

sucrose)sucrose)– Wait 15 minutesWait 15 minutes– Re-check blood sugarsRe-check blood sugars– Re-treat if <4 mmol/lRe-treat if <4 mmol/l

QuestionQuestion

Which food will raise blood sugar Which food will raise blood sugar quicker?quicker?

–Whole wheat bread or pita bread?Whole wheat bread or pita bread?

–Shredded Wheat or Cheerios?Shredded Wheat or Cheerios?

–Pasta or short-grain rice?Pasta or short-grain rice?

–Sweet potato or Russet potato?Sweet potato or Russet potato?

–Popcorn or Rice Cakes?Popcorn or Rice Cakes?

Other Nutrients of Importance?Other Nutrients of Importance?

Which other nutrients in foods will Which other nutrients in foods will decrease the glucose surge when eaten decrease the glucose surge when eaten with CHO foods?with CHO foods?– ProteinProtein– FatFat– FiberFiber

Your patient, SandraYour patient, Sandra

55 YO, diagnosed with type 2 diabetes 55 YO, diagnosed with type 2 diabetes one-year ago.one-year ago.Blood sugars are not in control.Blood sugars are not in control.Typical day of blood sugars:Typical day of blood sugars:– am 9, 2 hour post breakfast 10am 9, 2 hour post breakfast 10– Before lunch 8, 2 hour post lunch 9Before lunch 8, 2 hour post lunch 9– Before supper 9, 2 hour post supper 15Before supper 9, 2 hour post supper 15– Before bed 13-14Before bed 13-14

Ideas for management?Ideas for management?

Management Management

Start insulin with largest meal of the day Start insulin with largest meal of the day (supper)(supper)

Typical supper:Typical supper:2 c kraft dinner, ½ c cottage cheese, 3 toast with 2 c kraft dinner, ½ c cottage cheese, 3 toast with peanut butter, 1 c ice-cream for dessert.peanut butter, 1 c ice-cream for dessert.

If we were giving pt insulin based on CHO If we were giving pt insulin based on CHO consumption, what would you recommend consumption, what would you recommend Sandra take for insulin at this meal?Sandra take for insulin at this meal?

FiberFiber

Food with 5+ grams of fiber per serving:Food with 5+ grams of fiber per serving:– Subtract this from total CHO content in serving.Subtract this from total CHO content in serving.

ExampleExample

1/3 cup All-Bran Buds1/3 cup All-Bran Buds

23 grams CHO, 12 grams fiber23 grams CHO, 12 grams fiber

23-12= 11 grams of digestible CHO.23-12= 11 grams of digestible CHO.

Prevention of Type 2 DiabetesPrevention of Type 2 Diabetes

All countries agree that we need a All countries agree that we need a structured program for weight loss and structured program for weight loss and physical activity.physical activity.For IGT, recommend that metformin For IGT, recommend that metformin and/or acarbose be used to prevent and/or acarbose be used to prevent diabetes onset.diabetes onset.2008 Canadian Practice Guidelines for 2008 Canadian Practice Guidelines for Diabetes Prevention and management Diabetes Prevention and management are released now for more information.are released now for more information.

Management of GDMManagement of GDM– Nutritionally adequate diet following Canada’s Nutritionally adequate diet following Canada’s

Food Guide for healthy eatingFood Guide for healthy eating– Adequate in energy to promote normal weight Adequate in energy to promote normal weight

gain and prevent ketonuriagain and prevent ketonuria– Low in simple sugars and juicesLow in simple sugars and juices– Food distributed between 3 small meals and 3 Food distributed between 3 small meals and 3

healthy snacks at regular timehealthy snacks at regular time– Adequate fluid intake (6-8 cups/day)Adequate fluid intake (6-8 cups/day)– Sweetener may be used within the acceptable Sweetener may be used within the acceptable

daily intake limits.daily intake limits.– Avoid alcoholAvoid alcohol

Management of PostpartumManagement of Postpartum

– Encourage breastfeedingEncourage breastfeeding

– Encourage maintaining/ achieving Encourage maintaining/ achieving healthy wt. for ht. for prevention or healthy wt. for ht. for prevention or delay of diabetes later in life and/or delay of diabetes later in life and/or subsequent pregnanciessubsequent pregnancies

– Encourage to follow diet suggested Encourage to follow diet suggested for management of diabetes early in for management of diabetes early in subsequent pregnanciessubsequent pregnancies

Key MessagesKey Messages

– Nutrition therapy can reduce the glycated Nutrition therapy can reduce the glycated hemoglobin by 1.0-2.0%.hemoglobin by 1.0-2.0%.

– Consistency in carbohydrate intake + regularity Consistency in carbohydrate intake + regularity in meal time and meal spacing may help control in meal time and meal spacing may help control blood glucose and body weight.blood glucose and body weight.

– Replacing high-glycemic index carbohydrates Replacing high-glycemic index carbohydrates with low-glycemic index carbohydrates in mixed with low-glycemic index carbohydrates in mixed meal has a clinically significant effect on meal has a clinically significant effect on glycemic control in people with Type 1 or type 2 glycemic control in people with Type 1 or type 2 diabetes.diabetes.

Resources Used TodayResources Used TodayTuomilehto, J et al. (2001). Prevention of type 2 diabetes Tuomilehto, J et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired mellitus by changes in lifestyle among subjects with impaired glucose tolerance. glucose tolerance. New England Journal of Medicine, 344, New England Journal of Medicine, 344, 1343- 1343-1350.1350.

Knowler, W. et al (2002). Reduction in the incident of type 2 Knowler, W. et al (2002). Reduction in the incident of type 2 diabetes with lifestyle intervention or metformin. diabetes with lifestyle intervention or metformin. New England New England Journal of Medicine, 346,Journal of Medicine, 346, 393-403. 393-403.

Management of Diabetes in Pregnancy: Challenges and Trends. Management of Diabetes in Pregnancy: Challenges and Trends. Meltzer, S. Canadian Journal of Diabetes, 2005; 29(3); 246-256.Meltzer, S. Canadian Journal of Diabetes, 2005; 29(3); 246-256.

Canadian Diabetes Association 2008 Clinical Practice Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes (2008); 32 (Supplement 1) Canada. Canadian Journal of Diabetes (2008); 32 (Supplement 1) ..